Woman With Dull Daily Headaches and Episodic "Knockout" Attacks

A 40-year-old woman reports increasingly frequent and severe headaches during the past few months. She has had bouts of severe headaches since college, and episodic migraine was diagnosed a decade ago. She uses over-the-counter products (ibuprofen, ketoprofen, or aspirin) at the onset of an attack; if these fail to relieve symptoms, she takes hydrocodone/ acetaminophen. During her worst attacks, she is typically forced to halt her activities, is unable to eat or drink, and may vomit. For unresponsive or persistent (more than 24-hour) attacks, her husband drives her to the urgent care center for intravenous hydration, intramuscular promethazine, and additional doses of hydrocodone/acetaminophen. According to the patient, a visit to the urgent care center “completely ruins our day.”